Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes.

OBJECTIVE: To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate. METHODS: A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis. RESULTS: Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification. CONCLUSION: Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.

Practical and functional classification of the double urethra: A variable, complex and fascinating malformation observed in 20 patients.

INTRODUCTION: Urethral duplication is a rare and variable malformation of the urinary tract, with non-univocal and complex management. In addition, different classification schemes have been proposed, but none have considered all the possible variants. OBJECTIVE: To report experience with the management of 20 urethral duplication patients and propose a classification of this anomaly. MATERIALS AND METHODS: A retrospective analysis collecting information regarding 20 patients (Table) with urethral duplication treated at a single institution over the past 40 years. Three females and 17 males were treated: two had vesico-urethral duplication, eight had urethral duplication with a single bladder, and eight had 'λ' duplication. RESULTS: Immediate postoperative complications included urethral dehiescence (n = 1) and urethral stenosis (n = 2). The progressive augmentation by dilating the urethra (PADUA) technique was ineffective. During follow-up, the following were recorded: urinary incontinence (n = 2), urinary tract infection (n = 3), hypertension (n = 3) and erectile dysfunction (n = 1). All patients were satisfied with the aesthetic result. DISCUSSION: Urethral duplication is a rare anomaly with male preponderance. Four types of duplication were described, on the basis of anatomy and management: vesical and urethral duplication (type 1), urethral duplication with single bladder (type 2), 'λ-type' duplication (type 3) and 'miscellanea' (multiple urethral channels, spindle urethra, other female forms, type 4). A full description of the malformation and surgical approach was given for each type. The advantages of the classification were compared with the literature. CONCLUSIONS: The proposed classification should be a useful tool, based on the required surgical approach, even if surgery should be tailored to the patient. It is important to restore the anatomy and achieve urinary continence. Surgery can be challenging and a multi-step process, especially in cases of 'λ' duplications.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

BACKGROUND: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. METHODS: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. RESULTS: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. CONCLUSIONS: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

An unusual variant of urethral duplication: an addition to the Effman classification.

A rare association of horseshoe kidney with pyelic fusion with crossed single ureter along with a rare unusual variant of complete urethral duplication is described. We review the available literature on this rare association and present its management.

[Dynamic magnetic resonance imaging in the diagnosis of male urethral diseases (a complex of pulse sequences)].

OBJECTIVE: To estimate the capabilities of a developed complex of pulse sequences (PSs) for magnetic resonance imaging (MRI) to diagnose male urethral diseases. MATERIAL AND METHODS: The results of MRI, X-ray contrast retrograde urethrography (RUG), and voiding cystourethrography (VCUG) were analyzed in 46 patients of different ages who were treated for suspected urethral pathology at the Urology Unit, Rostov State Medical University Clinic. RESULTS: An algorithm is proposed for tomographic examination of the male lower urinary tract, which involves patient preparation and positioning, a list of PSs and the order of their use, and their parameters. The MRI semiotics of urethral stricture disease is described. There is information on the clinical application of MRI in urologic practice, which is compared with the results of other medical imaging and the data of surgical intervention and histological examination of the material obtained. CONCLUSION: Along with the known advantages of MRI over other radiation techniques, the complex of PSs proposed to study the male urethra surpasses conventional X-ray contrast RUG and VCUG in diagnostic informative value. This MRI technology can reliably identify and accurately locate stricture or obliteration of the urethra in its all portions and determine the extent and degree of abnormal urethral narrowing, as well as provides a way of estimating the extent of fibrous changes in the spongy body.

Development of Korean Academy of Medical Sciences Guideline rating the physical impairment; kidney, bladder, urethra, male and female reproductive systems (preliminary report).

For the evaluation of the kidney impairment, serum creatinine concentrations or glomerular filtration rates are mainly used, and the conditions of solitary or transplanted kidney and chronic dialysis are also taken into the considerations. Some symptoms and signs of the chronic renal disability in spite of adequate treatment add one additional grade. For evaluating bladder and urethral impairment, the criteria include voiding symptoms and signs. The patients with urinary diversions have impairment grades depending on the alteration of upper urinary tract function. For penile impairment, the degrees are evaluated using the international index of erectile function, nocturnal penile tumescence and color doppler ultrasonography. For evaluating impairment of other male reproductive organs, functional and anatomical changes of these organs, analysis of the semen or hormones and the state of solitary testis are used as the criteria. For evaluating impairment of female reproductive organs, pregnancy potential, requirement of continuous treatment and the ability of sexual intercourse are used. Also, degree of impairment is modified according to the ages in evaluating female reproductive systems. We have tried to make this evaluation system objective, scientific, and convenient, but still find it leaving much to be desired.

Classification of female genito-urinary tract fistula: a comprehensive review.

INTRODUCTION AND HYPOTHESIS: The aim of this paper is to review proposed classifications for genito-urinary fistulae. METHODS: A comprehensive literature review of historical texts, peer review publications, and abstracts was used to compile a listing of the existing genito-urinary fistula classification systems. RESULTS: The absence of an accepted standardized classification for female genito-urinary fistulae has resulted in the proliferation of a number of individually devised categorizations. Fistulae are described by size, location, degree of vaginal scarring, and type (whether it involves the bladder, rectum, intestines, uterus, etc). In addition, most classification systems have not been subjected to outcomes research, making them primarily descriptive in nature. CONCLUSIONS: There is a lack of consensus among fistula surgeons in adopting a standardized classification system or systems. Comparative assessment of studies and outcomes is not possible without a standardized classification system. Currently, there is no accepted standardized classification for female genito-urinary fistula.

Development of Korean Academy of Medical Sciences Guideline Rating the Physical Impairment; Kidney, Bladder, Urethra, Male and Female Reproductive Systems (Preliminary Report)

For the evaluation of the kidney impairment, serum creatinine concentrations or glomerular filtration rates are mainly used, and the conditions of solitary or transplanted kidney and chronic dialysis are also taken into the considerations. Some symptoms and signs of the chronic renal disability in spite of adequate treatment add one additional grade. For evaluating bladder and urethral impairment, the criteria include voiding symptoms and signs. The patients with urinary diversions have impairment grades depending on the alteration of upper urinary tract function. For penile impairment, the degrees are evaluated using the international index of erectile function, nocturnal penile tumescence and color doppler ultrasonography. For evaluating impairment of other male reproductive organs, functional and anatomical changes of these organs, analysis of the semen or hormones and the state of solitary testis are used as the criteria. For evaluating impairment of female reproductive organs, pregnancy potential, requirement of continuous treatment and the ability of sexual intercourse are used. Also, degree of impairment is modified according to the ages in evaluating female reproductive systems. We have tried to make this evaluation system objective, scientific, and convenient, but still find it leaving much to be desired.

Current evaluation and management of female urethral diverticula.

The identification of female urethral diverticula remains a challenging problem for many clinicians. Many of these patients are often undiagnosed or misdiagnosed due to a clinical presentation that frequently mimics other pathologic processes. There can be significant variation in the urethral diverticular anatomy in terms of size, location, and configuration. This update provides a succinct and comprehensive review of the clinical presentation, evaluation, and treatment options for female urethral diverticula.

Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging.

OBJECTIVES: We evaluated the surgical outcomes of transvaginal diverticulectomies classified using magnetic resonance imaging (MRI). METHODS: We evaluated 30 women (mean age: 46.4 yr; range: 31-73 yr) who were followed up for at least 12 mo after urethral diverticulectomies (mean follow-up: 29 mo; range: 12-93 mo). Characteristics of urethral diverticula were confirmed before surgery by MRI. Diverticula were classified as simple, U-shaped, or circumferential according to MRI features. Transvaginal excisions of urethral diverticula were performed using vaginal flaps and three-layer closures. Cure was defined as the absence of a diverticulum and symptoms. RESULTS: Seventeen cases (57%) had simple diverticula, three (10%) had U-shaped diverticula, and 10 (33%) had circumferential diverticula. After the first operation, 23 cases (77%) were cured. None of the simple diverticula recurred, but 33% of the U-shaped and 60% of the circumferential diverticula did recur. Of the seven recurrent cases, three did not require a second operation because their symptoms resolved. Of the four cases that underwent a second operation, three were cured and one was cured after two additional operations. The success rate for circumferential diverticula after initial diverticulectomies was less than that of simple or U-shaped diverticula (p<0.05). Location, size, and multiplicity of urethral diverticula did not affect the surgical outcome (p>0.05). CONCLUSIONS: Transvaginal diverticulectomy is effective for treatment of female urethral diverticula. For circumferential urethral diverticula, however, surgical procedures should be adapted to achieve complete resections of the diverticulum.

[Trauma to the anterior urethra: diagnosis and management]. / Traumatisme de l'urètre antérieur: diagnostic et traitement.

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).

Initial management of anterior and posterior urethral injuries.

The key to the initial management of a urethral injury is prompt diagnosis, accurate staging of the injury, and properly selecting an intervention that minimizes the overall chances for the debilitating complications of incontinence, impotence, and urethral stricture. Although somewhat controversial, blunt traumatic posterior injuries generally are managed best by primary realignment (when feasible), straddle injuries of the bulbar urethra by suprapubic urinary diversion, and penetrating urethral injuries by primary repair and urinary diversion.

Diagnosis and classification of urethral injuries.

Urethral injuries are uncommon and rarely life-threatening in isolation. They are, how-ever, among the most devastating urinary system injuries because of significant long-term sequelae, including strictures, incontinence, erectile dysfunction, and infertility. Urethral trauma may be categorized by mechanism of injury (ie, blunt versus penetrating injury) and by location (ie, posterior versus anterior urethra). Injuries to the posterior urethra are classically associated with pelvic fractures, while anterior urethral trauma usually arises secondary to injudicious instrumentation or perineal straddle injury. This article reviews the major etiologies and mechanisms of urethral trauma, describes how these injuries are diagnosed, and explains classifications of urethral trauma. Timely and accurate diagnosis and classification of urethral injuries leads to appropriate acute management and reduced long-term morbidity.

[Incomplete urethral duplication in a male. A case report]. / Duplicidad uretral incompleta en un varón. Aportación de un nuevo caso.

Urethral duplication is a rare congenital anomaly affecting mainly males and being usually diagnosed during paedriatric age. We report a 20 year old male complaining of double urethral meatus with double urinary stream. Physical examination confirmed and additional hypospadic meatus below a normally placed urethral meatus. Retrograde urethro-cystography and voiding cysto-urethrograms showed two distinct urethras originating from a common bladder neck and the diagnosis of Effmann type IIA2 incomplete urethral duplication was made. No treatment was felt to be applied after associated anomalies were ruled out.

Duplicidad uretral incompleta en un varón. Aportación de un nuevo caso / Incomplete urethral duplication in a male. A case report

La duplicidad uretral es una rara malformación congénita que afecta mayoritariamente al varón y que se diagnostica en los primeros años de la vida. Presentamos el caso de un varón de 20 años de edad que consultó por la presencia de un doble chorro y de un doble orificio uretral a nivel del glande. La uretro-cistografía retrógrada y miccional mostró la presencia de una uretra con un origen vesical único que se bifurcaba en su porción más anterior, correspondiéndose con una duplicidad tipo IIA2 de la clasificación de Effmann. Descartadas la presencia de otras anomalías, se decidió por la abstención terapéutica

Urethral duplication is a rare congenital anomaly affecting mainly males and being usually diagnosed during paedriatric age. We report a 20 year old male complaining of double urethral meatus with double urinary stream. Physical examination confirmed and additional hypospadic meatus below a normally placed urethral meatus. Retrograde urethro-cystography and voiding cysto-urethrograms showed two distinct urethras originating from a common bladder neck and the diagnosis of Effmann type IIA2 incomplete urethral duplication was made. No treatment was felt to be applied after associated anomalies were ruled out

American Urological Association Symptom Index for lower urinary tract symptoms in women: correlation with degree of bother and impact on quality of life.

OBJECTIVES: To determine first whether the American Urological Association Symptom Index (AUASI) correlates with the degree of bother caused by lower urinary tract symptoms (LUTS) in women and whether the association varies with a woman's age and continent status; and second, whether the AUASI and degree of bother caused by symptoms correlate with a woman's quality of life (QOL) and whether the association varies with a woman's age and continent status. LUTS occur in women and may produce significant bother and affect their QOL. The AUASI has been used to evaluate LUTS in female patients; however, its correlation with the degree of bother and QOL has not been clearly established in women. METHODS: The charts of 1232 women who completed the AUASI, as well as the Symptom Problem Index and global QOL question, were reviewed. Spearman's rank order correlation was computed to assess the correlation between the AUASI and Symptom Problem Index. It was also computed after stratifying the women's age and continence status (continent versus incontinent). A linear regression model was applied, with the AUASI and Symptom Problem Index as the response variables and QOL as the continuous explanatory variable. RESULTS: The mean age was 54.6 years. Six hundred women (49%) were incontinent. Spearman's rank order showed a strong correlation between symptoms and problems caused by symptoms (0.858, P <0.0001). The correlation existed throughout various age groups and was independent of coexisting incontinence. The symptoms correlated with QOL in a similar pattern. CONCLUSIONS: The AUASI accurately described LUTS in women and, as with men, is a good indicator of the degree of bother and affect on QOL.

Terms used to describe urinary tract infections--the importance of conceptual clarification.

Inaccuracies in medical language are detrimental to communication and statistics in medicine, and thereby to clinical practice, medical science and public health. The purpose of this article is to explore inconsistencies in the use of some medical terms: urinary tract infection, bacteriuria and urethral syndrome. The investigated literature was collected from medical dictionaries, textbooks, and articles indexed in Medline(R). We found various practices regarding how the medical terms should be defined, and had great difficulty in interpreting the status of the statements under the heading of 'definition'. The lesson to be learned, besides a reminder of the importance of clearly defined medical concepts, is that it must be explicitly stated whether what is presented as a definition is to be considered as defining criterion, as recognising criterion or as characteristic of the disease entity.

[Female urethral diverticuli]. / Divertículos uretrales femeninos.

OBJECTIVES: To review the etiopathogenic, diagnostic and therapeutic criteria for female urethra diverticula. METHODS: Urethral diverticulum was diagnosed in four patients, all of them with recurring urinary tract infections and irritative voiding symptoms. The final diagnosis was established by VCUG (Voiding cystourethrography). Other procedures, more recent and more in use, are also referred. RESULTS: All patients required surgical treatment, three of them with good results and one without success. The therapeutic procedures most frequently used in the literature during the last decade are also mentioned. CONCLUSIONS: The milestone in the management of female urethral diverticula is to think on it in patients with lower urinary tract symptoms. Surgical excision when amenable obtains optimal results.

Colostomy for anorectal anomalies: high incidence of complications.

PURPOSE: The aim of this study was to characterize the type and incidence of complications related to colostomy formation in newborn infants with anorectal anomalies. METHODS: The authors reviewed a 5-year (1994 to 1999) experience of a single institution in the management of neonates with high and intermediate anorectal anomalies who required colostomy at birth. Patients with colostomy still in place have been excluded from the study to maximize the chances of detecting colostomy-related complications. RESULTS: There were 80 neonates with anorectal malformations, of whom, 49 (31 boys and 18 girls) were included in the study. The site of colostomy was sigmoid colon (n = 32), transverse colon (n = 7), and descending colon (n = 10). Thirty-nine colostomies were loop, and the remaining 7 were divided. The median birth weight was 2.96 kg (range, 1.46 to 3.88). The age at colostomy formation was 2 days (range, 1 to 210). Mechanical complications related to colostomy formation were observed in 16 infants (32%) with 3 infants having more than 1 mechanical complication. These included prolapse in 8 (50%), intestinal obstruction (adhesions, intussusception, and volvulus) in 7 (44%), and skin dehiscence in 3 (19%). One neonate had necrotizing enterocolitis (NEC) after colostomy formation. Urinary tract infection was observed after colostomy in 14 infants (29%). The incidence of urinary tract infection was not higher in infants who had loop colostomy (11 of 39, 28%) compared with infants who had divided colostomy (3 of 10, 30%). There were no differences in the incidence of colostomy-related complications and urinary tract infection between male and female infants. There were no deaths in this series. CONCLUSIONS: Formation of colostomy for anorectal anomalies should not be considered a minor procedure. In our experience the incidence of complications after colostomy formation is high. The incidence of urinary tract infections does not seem to be affected by the type of colostomy performed.